The importance of a common global health definition: How Canada’s definition influences its strategic direction in global health

In late 2011, the Expert Panel on Canada’s Strategic Role in Global Health (herein: the panel) selected a global health definition for Canada. This decision is significant as the chosen definition forms the foundation of the panel’s forthcoming recommended strategic role for Canada in global health. In turn, the global health community can draw lessons from Canada’s decision to inform their own understanding of the term and demystify priority setting. In this paper we examine the five definitions considered by the panel and analyze the core characteristics of each in order to understand the rationale for the final choice as well as the implications of the chosen definition. To understand the basis upon which Canada will build its strategic direction for global health it is useful to frame this analysis in light of the other short-listed definitions.

I n late 2011, the Expert Panel on Canada' s Strategic Role in Global Health (herein: the panel) selected a global health defi nition for Canada. This decision is signifi cant as the chosen defi nition forms the foundation of the panels forthcoming recomended role for Canada in global health. In turn, the global health community can draw lessons from Canada' s decision to inform their own understanding of the term and demystify priority setting. In this paper we examine the fi ve defi nitions considered by the panel and analyze the core characteristics of each in order to understand the rationale for the fi nal choice as well as the implications of the chosen defi nition. To understand the basis upon which Canada will build its strategic direction for global health it is useful to frame this analysis in light of the other short-listed defi nitions.

WHY IS THE DEFINITION OF GLOBAL HEALTH IMPORTANT?
There has been a tremendous amount of discussion about global health without rooting the term itself to a common defi nition. Countless books and journal articles have been written and university programs have been designed around global health without a defi nition of the term. There are numerous examples of work being done in this fi eld without a clear defi nition in place [29,30]. Indeed, it is often not clear how people and organizations engaged in global health are using the term. An analogy would be for a medical team to discuss an intervention for a patient with condition 'x', without an agreed-upon defi nition of the condition itself. Because global health is composed of, and re-

BACKGROUND
Current global health trends, including epidemiological and demographic transitions, the rising burden of disease, climate change and the increasing awareness of global disparities in health, have heightened interest in the fi eld of global health among the international medical and public health communities [1][2][3][4]. Yet, there is a considerable amount of ambiguity and controversy about what 'global health' means [5,6].
In September 2010, the Canadian Academy of Health Sciences, with the assistance of the Council of Canadian Academies, brought together 15 Canadian global health experts to form the Expert Panel on Canada' s Strategic Role in Global Health [7,8]. The panel was tasked with assessing whether Canada ought to play a more strategic role in global health and, if so, to identify potential roles [7]. According to the Canadian Academy of Health Sciences, "Canada does not have a national multi-sectoral strategy to address the increasingly complex issue of global health" [7]. In order to frame deliberations about potential strategic roles for 1 In a report published by the Expert Panel on Canada's Strategic Role in Global Health, the panel selected a global health definition for Canada. As the definition chosen by the expert panel provides the foundation from which Canada identifies its strategic roles in global health, understanding the definition sheds light on the trajectory and future role of Canada in the global health field. The decision also signals to the international global health community the likely future direction for Canada's global health initiatives.
Canada in global health, the expert panel felt a common defi nition of global health was necessary [7,9]. Each of the fi ve defi nitions had been widely disseminated in leading peer-reviewed health journals or had been developed by key actors in the research and practice of global health [9].  Table 1) [7,12]. The purpose of this essay is to outline an approach for evaluating global health defi nitions in order to ultimately select the most appropriate defi nition. In this paper we analyze the fi ve defi nitions short-listed by the panel of Canadian global health experts [8], we deconstruct the characteristics of each and consider the implications on strategic priorities and initiatives of including or excluding these characteristics in a defi nition of global health.
The characteristics of each defi nition were identifi ed by inductive analysis, which allows characteristics to emerge from patterns found in the defi nitions being examined without presupposing what these characteristics will be [15]. We read and analyzed the defi nitions independently in order to identify distinct characteristics and to consider their role in a defi nition of global health. Consensus on the characteristics was reached through group discussion of both the defi nitions and potential examples of the different characteristics. The defi nitions were then coded for the occurrence or non-occurrence of each characteristic [9].
We determined whether a characteristic is primary or secondary by examining how it is portrayed in the literature. Primary characteristics are those that the global health grey and peer-reviewed literature portray as essential to a con- Table 1 Inductive analysis of global health defi nitions Brown: "Global health" in general, implies consideration of the health needs of the people of the whole planet above the concerns of particular nations. The term "global" is also associated with the growing importance of actors beyond governmental or intergovernmental organizations and agencies. [ cept of health that is differentiated as global. Without these characteristics, the term global health would cease to be distinct from other areas of health or it would be too vague to be actionable. Secondary characteristics are those mentioned in the literature that add detail or fi ne-tune the concept but are not regarded as crucial to the distinctiveness of global health or necessary for clarity.

PRIMARY AND SECONDARY CHARACTERISTICS OF GLOBAL HEALTH DEFINITIONS
Through the initial inductive analysis of the defi nitions, we identifi ed fi ve primary characteristics and four secondary characteristics overall ( Table 1).

PRIMARY CHARACTERISTICS
The fi ve characteristics considered primary are noted in the left side of Table 1.

Equity
The book, Global Health and Global Health Ethics, states that "the most striking feature about the state of global health is that it is characterized by such radical inequities" [5]. Indeed, basic statistics on inequities in health status and access....." provide the background of global health work. The lifetime risk for a Canadian woman dying from pregnancy complications or childbirth is 1 in 11 000 [5]; the lifetime risk for a woman in Niger is 1 in 7 [5]. Similarly, life expectancy at birth varies by over 50% depending on the country of birth. For those born in Canada or Japan, the average life expectancy is 80 years or more, whereas in Afghanistan and Sierra Leone life expectancy is approximately 40 years [5]. While a Canadian child diagnosed with acute lymphoblastic leukemia has a 90% chance of being cured; in the poorest countries of the world more than 90% of children diagnosed with this disease will die [16]. This is the context in which global health is practiced today.
Faced with such appalling disparities, much of global health research and practice is based on the underlying notion of equity [17,18]. In the past, international health focused on understanding "the other" or "the tropical" and was largely shaped in the context of colonialism. Today, the forces of globalization and the information and communication revolution have brought glaring global health disparities into full view and are the lens through which much of global health work is done. As a result, 'equity' was listed by the expert panel as the fi rst of three core principles that will guide the global health strategic vision for Canada, along with effectiveness and engagement [7]. Thus, it is telling that the expert panel chose a defi nition that not only includes the principle of 'equity', but one that emphasizes it in the very fi rst sentence.

Global conceptualization
A global conceptualization, differentiable from an international or supra-national perspective, is an integral component of a global health defi nition [19]. 'Global' health goes beyond the nation and focuses instead on vulnerable populations worldwide [6]. The difference between the terms international and global may appear small at fi rst, however, the implications are profound and at the very heart of the practice of global health and therefore also its defi nition. While international refers to nations interacting with nations, and supranational suggests bodies above the national level, global implies ignoring borders altogether and bridging gaps between need and care wherever they may exist. This is not to say that borders are porous or nations unimportant. National governments continue to provide the bulk of funding for development assistance in health, although the channels through which they are funneled are increasingly becoming global actors -such as the Global Fund and the Bill and Melinda Gates Foundation [20]. What is truly 'global' is the conceptualization of health itself, represented by the goal of health for all people, irrespective of location or nationality. Not surprisingly, all fi ve of the defi nitions considered by the expert panel embrace a global conceptualization and refer to the goal of "health of all people" or health for "people worldwide".

Causes
Causes are the contextual factors that determine a health issue. Causes can include the social, economic and physical environment, as well as individual characteristics and behaviors [21]. This characteristic highlights the fact that global health is not only a fi eld of study or practice but also a response to a burgeoning set of upstream challenges. Understanding the causes of these challenges is crucial for addressing global health status, and also for distinguishing its practice from humanitarian aid. Many of the biggest global health challenges are intimately tied to socio-political and economic forces related to resources, eg, famines; health infrastructure and skilled worker shortages; and access barriers to essential medicines, vaccines and health services. Thus to ignore the causes of global health challenges -in the fi eld and in the defi nition -is to miss the very reason for the existence of the fi eld. The challenges and disparities in global health are the raison d'être for the research, study and practice of global health. Unlike a science or an art, the fi eld of global health is very much about providing solutions to current problems. As such, it would be short-sighted not to consider the causes of global health problems in order to better formulate the solutions. Thus the causes ought to be included in a comprehensive and complete defi nition of the fi eld. Specifying causes narrowly or broadly will either focus or widen the scope of factors to be addressed in global health activities.

Means
Means are the methods and paths through which health activities take place. Depending on the conceptualization of global and the scope of causes, the means may range from providing individual-level clinical care or community education, through population-level disease prevention, to large scale national or international interventions [6]. Specifying the means pushes the concept from descriptive to prescriptive, or from 'what' to 'how' global health 'should' be carried out. Global health is not only a fi eld of study but also a fi eld of practice. Excluding means from the defi nition of global health would render it incomplete.

Solutions
Solutions are the activities undertaken to address health issues. The range of potential solutions varies with the extent of available resources, political will, time frame and scope of goals [22,23]. Solutions to global health challenges can, and often do, come from multiple sectors of society including the public system, academia, civil society and the private sector. Specifying global health solutions will guide priority setting for resource allocation under global health initiatives [24]. Decisions about solutions addressing imminent health problems will take precedence over investing in future health system capacity or tackling determinants of health [25,26]. Global health is about understanding the causes and fi nding the means to provide solutions to the challenges and disparities in health status of people worldwide. Thus solutions are a crucial component of a global health defi nition because they signal the fact that global health is not just a study or a practice, but a means to an end goal: the end of unnecessary, preventable and treatable inequities in global health status. Without including the solutions in the defi nition, the fi eld and the defi nition lose the glue that holds it all together since there would be little use of studying or practicing global health, with its accompanying disparities and challenges, if global health practitioners were not interested in providing the solutions to said challenges. Thus we consider solutions an essential component of a global health defi nition.

SECONDARY CHARACTERISTICS
The four characteristics considered secondary are noted in the right side of Table 1.

Source of obligation
One of the examined defi nitions [13] refers to the source of obligation for global health activity. Specifi cally, resourcerich entities are obligated to help those with fewer resources tackle their health problems. This characteristic is part of the extensive ethical discussion on obligations [5], as the source and nature of obligations have implications for conceptualizations, means and solutions in global health. Nevertheless, for a working defi nition, obligation is adequately refl ected in the primary characteristics. Specifi cally, the motive of global health is refl ected in the shared desire to fi nd solutions to challenges; while the feelings of or sources of obligation will undoubtedly vary across individuals and actors and cannot be summed up for the entire fi eld and all those who practice or study it.

Multidisciplinary approach
The primary characteristics of a global health defi nitionthat it crosses borders, has a multitude of causes and involves a range of means and solutions -implies the need for multiple professionals and disciplines in addition to medical professionals [27]. Although many global health issues require a multidisciplinary approach (for example, access to affordable antiretroviral treatments or implementing tobacco control strategies) it need not necessarily be so. Involving multiple disciplines all the time may not be necessary or effi cient. A multidisciplinary approach is often, but not always, needed and benefi cial and is therefore not an essential component of the fi eld of the defi nition.

Actors
Typically, global health issues are large, complex, and dynamic. Just as multiple disciplines may be required, the nature of global health issues also often leads to multiple Photo: Courtesy of Alasdair Campbell, personal collection actors using a variety of means to achieve different goals. Although the composition, funding mechanisms, values and goals of actors are important to the study and practice of global health [28], currently any individual or group can be an agent of global health. The all-inclusive nature of the work means that defi ning actors is not essential to the definition, though it is part of specifying means and solutions.

Reactive/proactive
Determining whether the provision of global health should be reactive, proactive or a combination of both depends on whether the focus is put upon current crises or future events that may result in crises. In a reactive approach, we respond to issues already at a crisis point when harm is likely already occurring and immediate solutions, such as famine relief, are required. A proactive response involves more foresight, for example, devising crop varieties adapted for climate change [2]. Determining a reactive, proactive or blended approach to action on a global health problem will direct resources to the most appropriate mix of solutions. These characteristics are descriptive of the means, the solutions, and the approach that is taken by global health actors; but are not descriptive of the fi eld, and therefore not an essential part of the defi nition.
While it would be diffi cult to reach agreement upon a single, international defi nition of global health, nation-level common defi nitions could assist in anticipating and coordinating strategies and initiatives across regions and sectors. The European Union has identifi ed and communicated their defi nition of global health [11] and the Expert Panel on Canada' s Strategic Role in Global Health selected the Koplan et al. [12] defi nition as the base for decision making in Canada.
Now that this defi nition is in place, it can provide direction to academics and organizations working in the fi eld. A different choice would have signifi cantly altered the practice of global health in Canada from the path set by the chosen defi nition. For example, by picking a defi nition that includes equity, it indicates that under Canadian global health strategies equity is an essential component. Had the expert panel selected the Brown defi nition [10], which does not include equity, it would have indicated that equity was not a primary concern from the Canadian perspective on global health. This would have had enormous implications for the future practice and study of global health in Canada.
With the chosen Canadian defi nition for global health the expert panel has provided the international global health community, researchers and policy makers an indication of future directions for Canadian global health initiatives. It would benefi t the international global health community to have all international actors working in the fi eld clearly indicate their own understanding of the term global health and the defi nition that frames their work.